Trauma, Stress, and Adjustment
The DSM-IV described adjustment disorders as a single classification. These are now
recognized as a heterogeneous group of disorders closely associated with stress, both
traumatic and non- traumatic. As such, adjustment disorders are classified in the DSM-5
along with trauma (including posttraumatic stress disorder, formerly included in DSM-IV
“Anxiety Disorders”) and reactive attachment disorder (formerly included in DSM-IV
“Disorders Usually First Diagnosed in Infancy, Childhood, or Adolescence”). The new
inclusive DSM-5 classification is called “Trauma- and Stress-Related Disorders.” The
common criteria across these disorders are exposure to a traumatic or stress-inducing
event.
Reactive Attachment Disorder
The DSM-IV included two subtypes of this disorder, representing distinct behavioral
expressions. The DSM-5 separates these subtypes into different diagnoses (though
they retain a single numerical identifier). Reactive attachment disorder (formerly the
withdrawn/inhibited subtype) results from neglect or other influences early in
development that negatively impact a child’s ability to form firm attachments. It is
characterized by a pattern of emotional withdrawal, limited or absence emotional
responsiveness, and limited positive affect. There may also be observed negative affect
incongruent with circumstance. The disorder generally appears during 9 months to 5
years of age. Diagnoses over the age of 5 years should be made cautiously, as little
research supports or describes the manifestation of this disorder in older children or
adolescents.
Disinhibited Social Engagement Disorder
In contrast to reactive attachment disorder, this new diagnosis—formerly the
indiscriminately social/disinhibited subtype of reactive attachment disorder—is also
linked to significant deficits in caregiving at very young ages. However, unlike reactive
attachment disorder, children with this diagnosis may have well-formed attachments.
This disorder is characterized by a pattern of indiscriminate interaction with adults,
such as a willingness to approach and interact with those who are unfamiliar.
Behaviors may also include excessively verbal or physical that is inconsistent with
cultural or age-appropriate norms. This disorder is also associated with attentionseeking behaviors, overfamiliarity, and inauthentic expression of emotion. Persistence
through adolescence is often accompanied by increased peer conflict.
Posttraumatic Stress Disorder (PTSD)
The DSM-5 includes several changes to this diagnosis. The revised PTSD diagnosis
can be used with adults, as well as with adolescents and children over the age of 6.
Criterion A, which pertains to the manner in which the traumatic event was experienced,
has been significantly revised to more specifically describe direct, indirect, and
witnessing experiences. Criterion A2 from the DSM-IV has been eliminated, thus
removing interpretations of subjective response.
Criterion B now includes more descriptive wording and is described as “intrusion
© 2014 Laureate Education, Inc.
Page 1 of 2
symptoms.” Criterion C from the DSM-IV has been separated into two symptom clusters:
persistent avoidance of associated stimuli (Criterion C in the DSM-5) and negative
alterations in cognitions and mood (Criterion D in the DSM-5). The criterion cluster
association with alterations in arousal and reactivity has expanded to include verbally or
physically aggressive behavior, recklessness, and self-destructive behavior. Another
important change in this diagnosis is the addition of specific criteria for children ages 6 or
younger. These criteria are founded in the criteria applicable to adolescents and adults;
however, they also include important age-specific variations. The DSM-5 also includes
important information regarding most common comorbidity differences between children
and adults diagnosed with this disorder. Oppositional defiant disorder and separation
anxiety disorder most commonly occur with this diagnosis in children.
Acute Stress Disorder
As with PTSD, the specific wording of Criterion A has been revised to more clearly
identify the manner in which the trauma was experienced, with the former criterion A2
from the DSM-IV eliminated entirely. Additional symptomology has been regrouped into
five main categories (intrusion, negative mood, dissociation, avoidance, and arousal)
with a total of 14 symptoms; individuals need to have 9 of the 14 symptoms present in
order to meet Criterion B. Onset and duration have been revised as well, noting the
presence of Criterion B symptoms to be present 3 days to 1 month after exposure to the
traumatic event.
Two additional new diagnoses are also part of this classification: other specified
trauma- and stressor-related disorder, and unspecified trauma- and stressorrelated disorder. Both of these diagnoses represent significant clinical distress or
impairment based on diagnostic criteria common to this classification, but do not meet
full criteria for a specific diagnosis. Clinicians should use other specified trauma- and
stressor-related disorder and add the specific reason for the more general diagnosis
(e.g., delayed onset of more than 3 months, or culturally-associated concepts). The
latter diagnosis—unspecified trauma- and stressor-related disorder—is used when
clinicians cannot (or choose not to) identify reasons for the inability to make a more
specific diagnosis, yet clearly observe multiple criteria from the trauma- and stressorrelated disorders classification.
Reference:
• American Psychiatric Association (2013). Highlights of changes from DSM-IV-TR
to DSM-5. Retrieved from
http://www.dsm5.org/Documents/changes%20from%20dsm-ivtr%20to%20dsm-5.pdf
© 2014 Laureate Education, Inc.
Page 2 of 2
J Youth Adolescence (2012) 41:1067–1077
DOI 10.1007/s10964-012-9746-y
EMPIRICAL RESEARCH
The Stress Response and Adolescents’ Adjustment:
The Impact of Child Maltreatment
Emily C. Cook • Tara M. Chaplin •
Rajita Sinha • Jacob K. Tebes • Linda C. Mayes
Received: 30 October 2011 / Accepted: 3 February 2012 / Published online: 23 February 2012
Ó Springer Science+Business Media, LLC 2012
Abstract Experience with and management of stress has
implications for adolescents’ behavioral and socioemotional development. This study examined the relationship
between adolescents’ physiological response to an acute
laboratory stressor (i.e., Trier Social Stress Test; TSST)
and anger regulation and interpersonal competence in a
sample of 175 low-income urban adolescents (51.8% girls).
Findings suggested that heightened reactivity as indicated
by cortisol, heart rate, and blood pressure was associated
with increased interpersonal competence and anger regulation. However, these findings were context dependent
such that, for youth high in self-reported child maltreatment, heightened reactivity was associated with decreased
interpersonal competence and anger regulation. Results
highlight the importance of considering how context may
condition the effect of stress reactivity on functioning
during adolescence.
Keywords Adolescence Anger regulation
Child maltreatment Interpersonal competence
Stress reactivity
E. C. Cook (&)
Department of Psychology, Rhode Island College,
600 Mt. Pleasant Ave., Providence, RI 02908, USA
e-mail: ecook@ric.edu
T. M. Chaplin R. Sinha J. K. Tebes
Department of Psychiatry, Yale University School of Medicine,
New Haven, CT, USA
L. C. Mayes
Yale Child Study Center, Yale University School of Medicine,
New Haven, CT, USA
Introduction
Anger regulation and interpersonal competence are
important indicators of socioemotional adjustment during
adolescence (Buhrmester 1990; Nicholas et al. 2008).
Anger regulation is a defining element of externalizing
problems (Bradley 2000); whereas interpersonal competence is important in forming and maintaining peer relationships (Demir and Urberg 2004). Within western
culture, two of the most important developmental tasks that
adolescents must accomplish are avoiding externalizing
behaviors and forming and maintaining peer relationships
(Roisman et al. 2004). Problems with anger regulation and
interpersonal competence in adolescence have been associated with increased physical and psychological problems
during adulthood (Harold et al. 2004; Roisman et al. 2004).
Thus, examining influences on anger regulation and interpersonal competence is paramount given their likely role in
helping adolescents successfully transition into adulthood.
Many factors may contribute to anger regulation and
interpersonal competence during adolescence and include
both physiological states and environmental influences
(Dodge and Pettit 2003; Reiss et al. 2000). Heightened
reactivity in response to a stressor has been associated with
both maladaptive behavior and healthy, adaptive functioning
during adolescence (Boyce and Ellis 2005; Obradovic et al.
2010; Susman 2006). Ellis and Boyce (2008) have suggested
that a heightened stress response is only a vulnerability in
highly stressful contexts (such as in the context of child
maltreatment by caregivers) but that in less stressful, supportive environments (such as supportive family environments) heightened reactivity is associated with positive
functioning. To explore this theory, the current study
examined whether the relationship between stress reactivity
to an acute laboratory based stressor (TSST) and two
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important indicators of adolescent’s socioemotional functioning, anger regulation and interpersonal competence, was
affected by adolescents’ recall and/or perception of maltreatment (e.g., physical and/or emotional abuse, neglect) in
a sample of low-income urban youth. Examining how child
maltreatment may modify the impact of stress reactivity on
youth’s functioning helps illuminate the conditions under
which reactivity contributes to maladaptive and adaptive
functioning during adolescence.
Stress Reactivity and Adjustment
A growing body of literature finds that variability in adolescents’ stress response both in the hypothalamic- pituitary- adrenal axis (HPA) and the autonomic nervous system
(ANS) is associated with adolescent functioning (Adam
and Kumari 2009; van Goozen et al. 2007). The ability to
activate the stress response system is a normative response
by the body that is necessary for survival and serves an
adaptive function in the short-term. However, chronic
activation of the HPA and ANS may contribute to
impairments in affective, behavioral, and cognitive functioning (McEwen 2007). Much of the literature on stress
response and adjustment suggests that heightened reactivity to stress is a risk factor for negative adjustment during
adolescence, both in regards to problems managing anger
and in interpersonal relationships (Granger et al. 1996;
Kobak et al. 2009; Miller et al. 2006). However, highly
reactive children may only experience negative outcomes
when reared in adverse environments, suggesting an
important role of context, defined here as environmental
rearing conditions (past or present), in the relationship
between stress reactivity and adolescent outcomes (Ellis
and Boyce 2008).
Biological Sensitivity to Context: Child Maltreatment
Heightened stress reactivity may have negative and positive associations with psychological functioning that are
context dependent. Ellis and Boyce (2008) propose that
individual differences in reactivity, developed as a result of
the interaction between genetic and early environmental
experiences, increase reactive individuals’ susceptibility to
both adverse and positive environments, which in turn
increases vulnerability for developing negative outcomes
under adverse conditions and positive outcomes under
supportive conditions. Specifically, heightened reactivity in
adverse environments is exacerbated and leads to upregulation of reactivity to stress in other environmental situations resulting in increased wariness in children and
problems managing anger and difficulties in interpersonal
relationships. Alternatively, for reactive youth who are
reared in more supportive, less stressful environments,
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children may use that heightened arousal response to
benefit from the social environment and develop good
emotion regulation skills and social competence (Ellis et al.
2005; Boyce and Ellis 2005). It may be that reactive
children are more reflective and conscious of self and, thus,
could potentially benefit more from supportive environments by taking advantage of what that environment has to
offer. To some extent, heightened reactivity may be typical
during the period of adolescence and only a problem under
conditions of environmental adversity with those individuals that experience trauma during this period or earlier
developmental periods being vulnerable to developing
dysregulated negative affect (Casey et al. 2010). Therefore,
the context in which youth develop is important to consider
when examining the relationship between stress reactivity
and adjustment.
Research has examined the role of different environmental conditions in the relationship between reactivity
and outcomes, but this research has predominately focused
on children. For example, research has demonstrated that
children who are both physiologically reactive and have
low father or mother involvement are most at risk for
mental health problems during childhood, with the lowest
rates of mental health problems among children who were
reactive and report low maternal depression (Boyce et al.
2006). Furthermore, heightened reactivity has been associated with positive adjustment under conditions of low
adversity but with externalizing problems under conditions
of high adversity (Obradovic et al. 2010). The current study
will contribute to this growing body of research by
examining Boyce and Ellis (2005) theory during adolescence and by focusing on child maltreatment.
Children who experience child maltreatment often
develop in contexts where there is a lack of warmth and
support, as well as high levels of violence, both of which
increase exposure to uncontrollable stress and upregulate
stress reactivity (Bell and Belsky 2007; van Voorhees and
Scarpa 2004). In turn, when youth are faced with acute
stressors in other contexts they may become overly aroused
and thus experience problems regulating emotions and
being competent in interpersonal relationships (Obradovic
et al. 2010). Thus, child maltreatment may create a context
under which youths’ reactivity to stressors is developed
and/or exasperated, which in turn, is associated with maladjustment (Cicchetti and Rogosch 2001).
Child maltreatment may be particularly problematic for
the development of socio-emotional problems for children
who are biologically reactive (Hart et al. 1996). Despite the
extensive amount of research on the relationship between
child maltreatment and socio-emotional problems, specifically externalizing problems, and the research on stress
reactivity and socio-emotional problems, little to no
research has been done on the interaction of maltreatment
J Youth Adolescence (2012) 41:1067–1077
and stress reactivity on socio-emotional problems and thus
marks an important area for future research (van Voorhees
and Scarpa 2004). There has been research during infancy
and childhood, however, suggesting that behaviorally or
biologically reactive children, as compared to less reactive
children, show the worst outcomes under conditions of
contextual adversity (e.g., low parental warmth) and the
best outcomes in supportive environments (Ellis et al.
2011; Obradovic et al. 2010). The current study extends
this research by examining whether current heightened
reactivity to an acute stressor in a laboratory setting coupled with reports of past child maltreatment is associated
with difficulties with anger regulation and interpersonal
competence during adolescence.
Hypotheses
There is accumulating evidence that youths’ stress
response contributes to psycho-social functioning during
adolescence. However, the conditions under which
heightened reactivity is associated with maladaptive functioning are not well understood. Thus, the current study
examines whether the nature of the relationship between
current stress reactivity to an acute stressor and adolescents’ adjustment varies in the context of childhood maltreatment. Specifically, we hypothesized that greater stress
reactivity to an acute stressor is associated with more anger
regulation difficulties and lower interpersonal competence
but only when youth report higher levels of child maltreatment and conversely greater stress reactivity to an
acute stressor is associated with less anger regulation difficulties and higher interpersonal competence when youth
report lower levels of child maltreatment.
Past research suggests that gender differences may exist
in the relationship between adolescents’ stress response and
social and behavioral outcomes (Chaplin et al. 2010; Natsuaki et al. 2009). Research generally has been mixed with
some studies finding a stronger relationship between stress
reactivity and outcomes for girls (Natsuaki et al. 2009) and
some studies finding a stronger relationship for boys (Tout
et al. 1998). Thus, all models controlled for gender to
account for these potential relationships.
Methods
Participants
This study utilized data from a longitudinal project that
examined development in high-risk low income urban
families who had been followed since birth, with twice
yearly assessments (N = 371). Families were originally
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recruited over a 5 year period from women registering for
prenatal care at a Women’s center of a large urban hospital
in the Northeast and from women in a delivery ward who
had not received prenatal care. During adolescence, a
subsample of the larger sample who were aged 14 to
16 years and who met the present study’s eligibility criteria
(no acute psychiatric condition, no serious medical condition, not pregnant, and IQ [ 80) were invited to participate
in the present laboratory based study of the effects of stress
of adolescents’ functioning. Based on these criteria, only
11 adolescents were excluded from participation. The 175
youth who participated were not different from the overall
sample on demographic characteristics (sex, race, and
mother education level). Adolescents were predominately
African American (86.9%) and 51.8% of participants were
girls. No mothers had greater than high school educations.
Adolescents’ primary caregivers were mostly biological
mothers (80%). At the time of data collection adolescents
were roughly 15 years of age (M = 15.36, SD = 1.01).
Procedures
Youth completed four sessions, spaced roughly 1 week
apart. During the first two sessions youth completed
questionnaires (e.g., Childhood Trauma Questionnaire),
computer tasks, and interviews that assessed adjustment.
Youth also participated in a laboratory-based stress session
during session three. Data from session four was not used
for the current study. All sessions lasted roughly 3 h and
both parental consent and adolescent asset were obtained
for the sessions. Adolescents and parents were told that
participation in all sessions was optional and that they had
the right to refuse any part of the assessments and payment
would still be awarded.
The Trier Social Stress Test conducted during session
three (TSST-C; Buske-Kirschbaum et al. 1997) was used to
examine adolescents’ stress reactivity to an acute stressor.
All laboratory sessions began at 4:15 pm as there is less
variation in cortisol at that time of day (Blackhart et al.
2007). The first part of the session involved a relaxation
period, which lasted 40 min, at which pretest measures of
blood pressure, pulse, cortisol, and self-reported emotion
were taken. The relaxation period consisted of a trained
research assistant guiding participants through breathing
exercises and muscle relaxation, which lasted on average
7 min. Following the relaxation period, youth participated
in the TSST-C. The TSST-C was used to induce social
stress in adolescents by asking youth to prepare and relay a
story (i.e., give a speech) to two unfamiliar adult ‘‘judges.’’
The adolescent was given a story stem and asked to prepare
the rest of the story for 5 min. After this, adolescents are
asked to give this speech for 5 min while standing in front
of the two judges. After the 5 min are finished youth were
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asked to complete a math task out loud in front of the
judges. Judges maintain a neutral expression and do not
help adolescents during the task. The TSST-C is one of the
most widely used and valid tests for eliciting a stress
response in adolescents (Kudielka et al. 2004). Adolescents
were debriefed regarding the TSST-C 20 min after the end
of the task.
Physiological and self-report assessments assessing
stress response were taken during the TSST-C (for HR),
immediately after the TSST-C, and then every 15 min
through 1 h of recovery. Adolescents were compensated
$50 for participation in each session, with an additional
bonus payment for completing all sessions. Most adolescents completed all sessions and thus there was very little
missing data (i.e., no measure used in the current study had
more than 15 participants missing data).
Measures
Stress Response
Salivary cortisol levels were measured as a biomarker of
HPA axis activation. Salivary cortisol is a well-established
non-invasive measure of HPA axis functioning that is
highly correlated with plasma cortisol (Adam and Kumari
2009). To obtain cortisol, saliva was collected using a
cotton swab that participants were asked to place between
their cheek and tongue for approximately 2 min. The swab
was put in a tube and placed directly on ice and stored at
-20C before being assayed in duplicate at a University
laboratory. The intra-assay coefficients of variation for the
assay kits ranged from 3.0 to 5.1%. Samples were taken
during the relaxation period, at baseline following the
relaxation period (40 min into the session), right before
adolescents prepared the story (47 min into the session),
immediately following the speech and math tasks (?65),
and every 15 min during recovery (?80, ?95, ?110,
?125). To examine adolescents’ stress response to the
TSST-C, baseline cortisol (40) was subtracted from peak
cortisol at 80 min. Forty minutes was chosen as baseline,
as opposed to assessments taken within the first 15–30 min
of the session, because presumably adolescents have
acclimated to the laboratory setting during the relaxation
period. Furthermore, data indicated that on average cortisol
was at its lowest value 40 min into the session. Eighty
minutes was chosen as ‘‘peak’’ because salivary cortisol
levels increase about 15 min after acute stressors. Baseline
minus peak is a valid measure of adolescents’ stress
response to an acute stressor.
To examine cardiovascular response, another important
indicator of stress reactivity, a Critikon Dinamap 120
Patient monitor was used to assess systolic blood pressure
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(SBP) and diastolic blood pressure (DBP). A pulse sensor
also was attached to the participant’s finger to provide
continuous heart rate (HR) measurement. Blood pressure
and heart rate were measured at baseline (?40), at task
preparation (?47), after the TSST-C (?65), and 15 min
after the task (?80). Additionally, HR was measured on
two occasions during the TSST-C (?55 & ?60). To
examine adolescents’ stress response, three measures of
cardiovascular reactivity were computed: (a) SBP peak (at
?65) minus baseline, (b) DBP peak (at ?65) minus baseline at 65 min, and (c) HR peak (an average of the 55 and
60 time points) minus baseline.
Anger Regulation
The Self-Report Adolescent component of the Behavior
Assessment Scale for Children Self-Report of Personality
(BASC-SRP; Reynolds and Kaphaus 2002) was used to
assess anger regulation and interpersonal competence. The
BASC-SRP is a highly valid instrument for assessing both
competence and maladjustment among adolescents (Stein
et al. 2007). The Anger Control subscale includes 14 items
intended to assess adolescents’ competency in controlling
their anger. Participants respond to both true/false items
and on a 4-point scale ranging from 1 (Never) to 4 (Almost
Always) to questions such as ‘‘When I get angry I can’t
think about anything else.’’ and ‘‘When I am angry I want
to hurt someone.’’ Higher scores indicated less anger
regulation.
Interpersonal Competence
The 7-item Interpersonal Relations Subscale from the
BASC-SRP was used to measure interpersonal competence
among adolescents and included a combination of true/
false items and a responses on 4-point scale ranging from 1
(Never) to 4 (Almost Always). Sample items included ‘‘I am
slow to make new friends.’’ and ‘‘My classmates don’t like
me.’’ Higher scores reflect more interpersonal competence.
The BASC-SRP is a widely-used measure and these subscales show good internal consistency, with alpha coefficients on subscales exceeding .80 (Reynolds 2010; Stein
et al. 2007).
Childhood Maltreatment
Adolescents’ experiences of childhood maltreatment were
assessed with the Childhood Trauma Questionnaire-short
form (CTQ-SF; Bernstein et al. 1994). The CTQ short-form
contains five subscales and 28-items that assess youths’
perceptions of physical and emotional maltreatment
(neglect and abuse) and sexual abuse during childhood and
adolescence. Because reports of sexual abuse was rare,
J Youth Adolescence (2012) 41:1067–1077
only the four subscales assessing physical and emotional
maltreatment were used; thus resulting in 20 items. Participants were asked to think about their experiences
growing up as a child and teenager and respond on a scale
from 1 (Never True) to 5 (Very Often True) to questions
such as ‘‘I felt unloved’’ and ‘‘I was punished with a belt, a
board, a cord, or some other object.’’ A sum score was
computed across the subscales, with higher scores indicating more perceived maltreatment (a = .73). Within our
sample scores ranged from 20–62 out of a possible range of
20–100 (M = 33.47, SD = 8.41). For analyses, we computed a dichotomous variable for high versus low CTQ
scores. Following recommendations from the manual,
youth falling below a score of 32 were classified in as low
maltreatment (51% of youth) and youth who scored above
32 as high in maltreatment (49% of youth; Bernstein and
Fink 1998). The CTQ has been found to be a reliable and
valid measure of childhood maltreatment in adolescent
samples. Specifically, adolescent reports on the CTQ have
been found to have good test–retest reliability, predictive
validity, and correlate with official reports of child maltreatment (Bernstein et al. 2003; Wolfe et al. 2001).
Analytic Strategy
The AMOS 18.0 structural equation modeling (SEM)
program was used to test the relationship between stress
reactivity and adolescents’ adjustment by maltreatment
history. Models included peak minus baseline scores as
measures of stress reactivity. Preliminary analyses
attempted to run growth curve models of the full trajectory
of stress response (from baseline to peak to recovery);
however, these models did not identify, potentially because
of small sample size and multicollinearity among the data
points. Thus, below we only present findings using peak
minus baseline as the measure of stress reactivity. Furthermore, preliminary confirmatory factor analyses in
AMOS indicated that a latent stress reactivity variable did
not fit the data well, and thus indicators of stress reactivity
were modeled as manifest variables in separate path
models.
Preliminary confirmatory factor analyses in AMOS
indicated that a latent stress reactivity variable did not fit
the data well, and thus indicators of stress reactivity were
modeled as manifest variables in separate path models.
Models were estimated separately because of concerns of
power due to a smaller sample size and, furthermore, we
were not interested in examining the relative effects of
different measures of stress reactivity on adolescents’
outcomes (Kline 2005). Model fit for all path models were
examined using the Chi-square goodness of fit statistic, the
comparative fit indices (CFI), and the root mean square
1071
error of approximation (RMSEA). A nonsignificant Chisquare indicated a good model fit (Byrne 2001). CFI values
of .90 indicated adequate fit of the data and RMSEA values
ranging from .05 to .08 indicated adequate model fit
(Thompson 2000). The significance threshold for all
models was set at p \ .05. The full information maximum
likelihood estimation procedure (FIML) was used to
address missing values because FIML produces less biased
estimates than does listwise case deletion or mean substitution (Acock 2005).
To test for moderating effects of child maltreatment, a
multiple-group path analysis was conducted with two
groups: those reporting high maltreatment and those
reporting low maltreatment. Multiple-group models are a
commonly used technique for testing moderation within
path analysis (Tomarken and Waller 2005). We used a
dichotomous moderator and ran a multiple group model, as
opposed to estimating a continuous interaction, because it
is very difficult to detect moderating effects with continuous variables and we wanted to maximize power to detect
potential group differences (McClelland and Judd 1993;
Henseler and Fassott 2010). To test for differences across
groups, two models were compared, one in which all
parameters were constrained to be equal and the other in
which the structural loadings were allowed to vary across
the two groups. Change in the Chi-square was examined
for statistical significance at the p \ .05 level. A significant
change in Chi-square between the models suggests that
group differences in the freed structural pathways exist,
and critical ratios above 1.96 were examined to locate
specific, significant group differences (Byrne 2001). We
chose to use SEM because it offers several advantages over
multiple regression that were pertinent to the current study.
Specifically, within SEM researchers have the ability to
assess the relationship between individual constructs as
well as overall model fit, the ability to take into account
error on the dependent variables, and the ability to address
missing data with FIML.
Results
Descriptive Statistics
Data were examined for normality. The cortisol data was
skewed. To address this, values that were greater than 3
standard deviations above the mean were reassigned a
value equal to three standard deviations above the mean
(following Susman et al. 2007). All other variables fell
within the range of normality and did not require transformation. Correlations among study variables, as well as
means and standard deviations are presented in Table 1.
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Table 1 Correlations among stress reactivity, adolescent’s adjustment, and child maltreatment
Variables
1. SBP reactivity
1
2
.31**
3. Heart rate reactivity
.14
4. Cortisol reactivity
4
5
6
7
8
–
–
2. DBP reactivity
5. Anger regulation
3
–
.41**
.19*
-.06
–
-.11
.22**
-.18*
.01
–
.04
–
.17*
.11
-.24**
–
6. Interpersonal
competence
.08
.11
7. Child maltreatment
8. Gender
.06
.01
-.04
.03
.01
-.13
.09
.08
.55**
-.18
-.30**
-.07
–
-.08
M
10.92
7.65
18.16
.06
11.02
16.15
1.69
–
SD
10.87
8.83
11.19
.13
6.87
2.55
.43
–
* Indicates a significant correlation at p \ .05 and ** indicates a significant correlation at p \ .01
Gender was controlled for in all analyses. Gender was
not significantly associated with any of the four indicators
of acute stress reactivity but was significantly associated
with anger regulation such that boys reported lower levels
of anger regulation than girls, b = -.18, p \ .05.
To get a better sense of current functioning across the
two groups (high child maltreatment and low child maltreatment), we also examined mean differences in demographics, protective factors within the family and at school,
perceived stress, adolescents’ functioning, and stress
response (Table 2). Analyses indicated that youth low in
child maltreatment reported more positive relationships
with parents, less perceived stress, and fewer problems at
school than youth high in child maltreatment. These
descriptive results provide preliminary evidence that youth
in the child maltreatment group were currently experiencing multiple stressors within their lives as compared to
youth in the non-maltreated group.
Stress Reactivity and Adolescents’ Adjustment
We first examined the relationship between four different
indicators of stress reactivity and interpersonal competence
and anger regulation for the full sample of youth (Fig. 1).
Models were estimated separately for the different stress
responses of heart rate, systolic blood pressure (SBP),
diastolic blood pressure (DBP), and cortisol. Chi- square
was highly non-significant for all models indicating good
model fit. Furthermore, CFI and RMSEA values from all
models ranged from .91 to .94 and .07 to .08, respectively,
Table 2 Comparison of youth
low in child maltreatment and
high in child maltreatment
Groups
Low in child
maltreatment (51%)
(M = 27.17, SD = 2.53)
High in child
maltreatment (49%)
(M = 39.76, SD = 7.46)
Demographics
Gender (female)
48.2%
55.4%
Age
15.30 (.97)
15.39 (1.03)
Current environmental stressors/supports
Positive parent–child*
19.79 (6.43)
14.91 (6.13)
School problems*
148.34 (21.92)
160.51 (25.83)
Perceived stress*
1.24 (.62)
1.76 (.73)
Stress response (peak–baseline)
Heart rate
17.04 (11.05)
19.38 (11.28)
Systolic blood pressure
Diastolic blood pressure
10.69 (10.15)
7.45 (8.67)
11.12 (11.72)
7.65 (9.13)
Cortisol
* Indicates that groups are
significantly different on
background characteristics at
p \ .05
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.0517 (.1389)
.0637 (.1335)
Adolescent functioning
Interpersonal Competence*
Anger Regulation*
16.85 (2.36)
15.45 (2.56)
8.10 (5.18)
13.88 (7.18)
J Youth Adolescence (2012) 41:1067–1077
SBP Stress
Response
SBP Stress
Response
.08
DBP Stress
Response
.12
.21*/-.01
Interpersonal
Competence
-.32*/.17*
Interpersonal
Competence
-.06
DBP Stress
Response
1073
.20*/.07
-.26*/-.13
-.18*
.21*/-.03
.14
Cortisol Stress
Response
Problems Anger
Regulation
.03
Cortisol Stress
Response
-.26*/.31*
Problems Anger
Regulation
.31*/-.07
.16*
-.03
-.23/.10
Heart Rate Stress
Response
Heart Rate Stress
Response
Fig. 1 Stress reactivity and adolescents’ adjustment. Although represented here in the same figure, separate models were estimated for
the four different indicators of stress reactivity. Standardized betas are
presented and * indicates significance at p \ .05 level. Dashed lines
indicate non-significant associations. All analyses controlled for
gender
indicating adequate model fit. Heart rate reactivity (i.e., an
increase in heart rate from baseline to peak) was significantly associated with interpersonal competence (b = .16,
p \ .05), and cortisol reactivity (i.e., an increase in cortisol
from baseline to peak) was associated with interpersonal
competence but only reached a trend level of significance
(b = .14, p = .09). Higher DBP reactivity (i.e., an increase
in DBP from baseline to peak) was associated with less
problems with anger regulation (b = -.18, p \ .05).
Results from these models suggested that adolescents with
higher stress reactivity, as indicated by heart rate reactivity
and DPB, were more likely to report interpersonal competence and less likely to report problems with anger
regulation.
Child Maltreatment, Stress Reactivity and Adolescents’
Adjustment
Adolescents low and high in child maltreatment differed on
their associations between stress reactivity and anger regulation and interpersonal competence. Specifically, results
from the omnibus group difference tests in all four models
indicated that there were significant changes in Chisquares, ranging from 14.59 to 24.87, when the paths were
allowed to differ for adolescents low and high in child
maltreatment (Fig. 2). In terms of anger regulation, when
the effect of cortisol reactivity on adolescents’ adjustment
was examined across groups, critical ratios indicated that
the relationship between cortisol reactivity and anger regulation difficulties was significant and positive for those
high in child maltreatment, b = .32, p \ .01 and significant and negative for those low in child maltreatment,
b = -.26, p = .02. When the relationship of SBP reactivity and anger regulation problems was examined across
groups there was a significant and positive relationship for
Fig. 2 Stress response adolescents’ adjustment, and child maltreatment. Although represented here in the same figure, separate models
were estimated for the four different indicators of stress reactivity.
Those low in child maltreatment are to the left and youth high in child
maltreatment are to the right of the diagonal. Standardized betas are
presented and * indicates significance at p \ .05 level. Models
control for gender
those high in child maltreatment, b = .17, p \ .05; this
relationship was significant and negative for youth low in
child maltreatment, b = -.32, p \ .001. The pattern of
findings between heart rate and anger regulation were
similar, with higher heart rate reactivity associated with
less anger regulation problems among youth low in child
maltreatment, b = -.23, p \ .01 and non-significant and
positive for youth high in child maltreatment, b = .10,
p = .28. DBP followed a similar but slightly different
pattern with higher DBP reactivity associated with less
anger regulation problems among youth low in child maltreatment, b = -.26, p \ .01 and non-significant and
negative for youth high in child maltreatment, b = -.13,
p = .20.
There also were significant differences between groups
for the relationship between stress reactivity and interpersonal competence. Critical ratios indicated that three of the
structural pathways differed for those low and high in child
maltreatment. The pathway from heart rate reactivity to
interpersonal competence was significant and positive for
youth low in child maltreatment, b = .31, p \ .001 but
was non-significant and negative for youth high in child
maltreatment, b = -.07, p = .46. Furthermore, the pathway from SBP reactivity, as well as the path from DBP
reactivity to interpersonal competence were significant and
positive for youth low in child maltreatment, b = .21,
p \ .05 and b = .20, p \ .05, respectively but non-significant for those high in child maltreatment, b = -.01,
p = .99 and b = .07, p = .51, respectively.
Discussion
The effect of child maltreatment on the relationship
between adolescents’ stress reactivity and adjustment is an
123
1074
important but understudied topic. This study contributes to
the literature by providing support for Ellis and Boyce’s
(2008) premise that heightened reactivity to stress is only a
vulnerability in highly stressful contexts but that in less
stressful, contexts heightened arousal is associated with
positive functioning. Furthermore, we contribute to the
literature by demonstrating empirically that child maltreatment conditions the relationship between stress reactivity and adolescents’ functioning in a sample of urban
youth. Specifically, we found that heightened reactivity to a
acute stressor was associated with adaptive functioning in
less adverse environments. Conversely, heightened reactivity was a risk factor for decreased anger regulation and
decreased interpersonal competence in more adverse
environments.
This is one of the first studies to examine the relationship between stress reactivity and anger regulation and
interpersonal competence in a low income urban sample of
adolescents. Findings from the sample as a whole suggested that heightened reactivity to an acute stressor
(defined as change in heart rate, cortisol, and blood pressure) was associated with increased interpersonal competence and anger regulation but the associations were only
modest. Modest associations are consistent with previous
research findings on the relationship between physiological
reactivity and adolescent outcomes (Granger and Kivlighan
2003; Obradovic et al. 2010). Furthermore, few studies
have been conducted with predominately low income
urban samples of youth, and the robustness of the stress
response and associations of the stress response and adolescent functioning may vary based on the race, SES, and
location of the sample (Jackson et al. 1999). Thus, it will be
important in future research to examine whether associations between stress reactivity to an acute stressor and
adjustment are comparable to the associations found in less
urban environments with predominately middle and upper
class European American youth. Another potential reason
for the modest associations is that within youth there is
variability in contextual influences that might affect the
relationship between stress reactivity and functioning.
Examining potential factors that may affect the nature of
the relationship between stress reactivity and youths’
functioning is a critical yet understudied topic of research
that may help explain the discrepancies in current research.
To this end and consistent with work done by Ellis and
Boyce (2008) and Gunnar et al. (2000), our findings suggested that heightened stress reactivity may be adaptive for
those low income urban youth who reported low levels of
childhood maltreatment. It may be that responding to social
evaluative stressors like the TSST with heightened reactivity is typically a healthy response for youth, allowing
them to be aroused appropriately when needed, which may
translate into better emotion regulation and interpersonal
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J Youth Adolescence (2012) 41:1067–1077
success. In contrast, for youth with relatively high levels of
recalled or perceived past maltreatment, we found either a
lack of association between stress response and adaptive
outcomes or a negative association. When youth show
heightened stress responses in the context of a non-supportive, maltreating environment, the consequences on
emotion regulation may be negative with youth being less
able to control emotion. This explanation is consistent with
Ellis’s and Boyce’s theory, as well as empirical work that
finds heightened reactivity to be only be a risk factor for
maladjustment in adverse environments (Essex et al. 2011;
Obradovic et al. 2010). Our findings were suggestive of this
pattern but, contrary to expectations, significant associations only emerged for the relationship between heightened
reactivity and anger regulation. It is noteworthy, that the
significant associations we see occur for anger regulation
and not interpersonal competence. Few studies have been
done that look explicitly at interpersonal competence.
Perhaps heightened reactivity is less problematic for
behaviors that are more dyadic and have less of an emotional regulation component. Future research examining
interpersonal competence during adolescence is important
given the salience of peer relationships during this developmental period (Roisman et al. 2004).
It is also plausible that a lack of findings within the
maltreated group occurred because youth who experience
chronic maltreatment and chronic stress arousal over many
years may develop a numbing or blunting of their stress
arousal response (Gunnar and Vazquez 2001), leading to
reduced range in stress response and ability to detect
findings in this group. However, in the present study, we
did not find that youth in the high maltreatment group
showed decreased levels or range of stress response than
the low maltreatment group. Nonetheless, emotional
blunting in maltreated youth will be an important factor to
consider in future studies of links between physiological
arousal response and socio-emotional adjustment in maltreated youth.
Drawing on these findings, programs aimed to improve
emotion regulation and interpersonal competence should
target those youth with high stress reactivity who also have
experienced maltreatment or other potential adverse
experiences. Prevention approaches directed toward helping parents learn more adaptive emotional regulatory skills
may also reduce the incidence of early maltreatment and/or
neglect and thus impact adolescent development through
impacting parental care and overall early environmental
nurturing conditions.
Limitations
This study is not without limitations. Most notably, data
were only collected at one point in time, and thus we
J Youth Adolescence (2012) 41:1067–1077
cannot make claims regarding causality and direction of
effects. This limits our ability to evaluate the claim from
Boyce and Ellis’s theory that a trait-like reactivity develops
as a product of both genetic and environmental conditions
that shape individual differences in reactivity in other
settings and developmental periods. To date, very few
studies have examined the associations between stress
reactivity and adolescents’ adjustment longitudinally and
as such this area of research is a priority. We also were not
able to assess at what point in time child maltreatment
occurred because the CTQ asks youth to report on maltreatment experiences growing up as a child. Thus, we do
not know if the context in which adolescents were currently
in was one in which they were experiencing child maltreatment. Examining at what point in time maltreatment
occurs is important because past research has suggested
that the impact of child maltreatment on functioning may
depend on the timing of maltreatment (Ireland et al. 2002;
van Voorhees and Scarpa 2004). The use of retrospective
reports also has been questioned as a valid assessment of
child maltreatment (Hardt and Rutter 2004). However, the
use of the CTQ during adolescence has been found to
correlate highly with official reports of child maltreatment
(Wolfe et al. 2001) and may not be as susceptible to recall
bias as reports collected several years later during adulthood (Everson et al. 2008). Nonetheless, future research
should collect more objective measures of child maltreatment, as well as assess the timing and duration of maltreatment for youth.
In the current study, we were interested in evaluating the
premise that heightened reactivity may be associated with
positive adjustment under supportive conditions and negative adjustment under adverse conditions. We did not,
however, specifically examine whether adolescents who
reported more supportive environments evidenced heightened reactivity that was associated with positive functioning. Thus, our findings may only be tapping into an absence
of risk as opposed to assessing differences in supportive
environments. Our results (Table 2) do indicate that those
youth who reported lower child maltreatment also reported
more positive parent–child relationships, less problems at
school, and less perceived stress, which suggests that in our
sample youth who reported less child maltreatment also
experienced more supportive environments than those
youth who reported more maltreatment.
We only modeled heightened stress reactivity as a
function of peak-baseline, and thus did not model the entire
stress response (baseline through recovery) nor did we
examine blunted reactivity. Examining different patterns
and trajectories of stress response (e.g., blunted vs. hyperreactivity and peak vs. baseline and recovery) is an
important area of research that may have implications for
understanding the disparate findings on acute stress
1075
response and adjustment (Gunnar et al. 2009). As stated in
the ‘‘Methods’’ section, we did attempt to run growth curve
models of the full trajectory of stress response; however,
these models did not statistically identify, potentially
because of small sample size and multicollinearity among
the data points. Future studies, with larger samples should
examine different patterns and trajectories of acute stress
response and the association with adolescents’ functioning.
Finally, a relatively small sample size may have resulted
in underpowered multiple group models. SEM typically
requires larger samples to obtain valid parameters, with
recommendations of 100 participants needed to obtain
reliable results (Thompson 2000). Our sample size per
group was less than 100 (n’s = 86, 87). However, path
models are not as complex as SEM models and may not
need as many participants as fewer parameters are generally estimated. The rule of thumb for SEM is that valid
parameters can be obtained with ratios of participants to
parameters at a minimum of 5:1 (Thompson 2000). Following this, our sample size of 175 is adequate to allow
estimation of 35 parameters. In our multiple group models,
only 26 parameters were estimated (13 per group); thus, we
were adequately powered.
Conclusion
This study broadens our understanding of how contextual
influences interact with biological systems (e.g., stress
response system) to affect adolescents’ adjustment. Findings suggest that heightened reactivity to stress is more of a
vulnerability in highly stressful environments here children
report child maltreatment but that in less stressful, environments heightened arousal is associated with interpersonal competence and anger regulation. Integration of
biological, social, and clinical domains is important for
pushing the field of adolescent development forward (Dahl
2004). Furthermore, findings from this study shed light on
the role of child maltreatment in the relationship between
heightened stress reactivity and adolescent adjustment. By
studying potential moderators that impact the effect of
stress reactivity on adjustment, we can inform intervention
efforts by identifying at what level to intervene and for
which youth intervention is needed.
Acknowledgments Support for this project and time working on
this manuscript was provided by the National Institutes of Health
(NIH) through grants T32DA019426 (Cook), K01-DA-024759
(Chaplin), P50-DA-16556 (Sinha), R01-DA-06025 (Mayes), R01DA-017863 (Mayes), KO5-DA-020091 (Mayes), and a grant from the
Gustavus and Louise Pfeiffer Research Foundation (Mayes). The
study sponsors had no involvement in the study design; collection,
analysis, and interpretation of data; the writing of the manuscript; or
the decision to submit the manuscript for publication.
123
1076
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Author Biographies
Dr. Emily C. Cook is an Assistant Professor of Developmental
Psychology at Rhode Island College. Her research interests include
individual and contextual influences on adolescents’ problem behaviors and social development and effective prevention and interventions for adolescents who exhibit problem behaviors.
Dr. Tara M. Chaplin is an Assistant Professor of Psychiatry at Yale
University. Her research interests are in the role of gender and
emotion regulation in the development of psychopathology and
substance abuse in children and adolescents. She is also interested in
the role of parent-adolescent interactions in the development of
substance abuse.
Dr. Rajita Sinha is a Professor in the Department of Psychiatry at
Yale University and Director of the Yale Interdisciplinary Stress
Center (YISC). Her research examines sex-specific neurobiological
mechanisms underlying stress in humans, neurobiological alterations
in stress and reward circuits associated with addictive disorders, and
developing effective addiction prevention and treatment strategies
that target stress and emotion regulation in individuals both at-risk for
and those with addiction problems.
Dr. Jacob K. Tebes is a Professor of Psychology in Psychiatry and
the Director of the Consultation Center at Yale University. His
research interests focus on on the promotion of resilience in at risk
populations, including the prevention of substance use among
adolescents; the integration of cultural approaches into practice,
research, and policy; prevention and community research methodology; and interdisciplinary team science.
Dr. Linda C. Mayes is the Arnold Gesell Professor of Child
Psychiatry, Pediatrics, and Psychology in the Yale Child Study
Center. Her research interests include early adversity, stress regulation, parental addiction, risk for drug use in adolescence, and neural
circuitry of social attachment and parental behavior.
123
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